Factors Influencing Physician Decision Making to Attempt Advanced Resuscitation in Asystolic Out-of-Hospital Cardiac Arrest

Abstract

The objective of this study was to identify the key elements used by prehospital emergency physicians (EP) to decide whether or not to attempt advanced life support (ALS) in asystolic out-of-hospital cardiac arrest (OHCA). From 1 January 2009 to 1 January 2017, all adult victims of asystolic OHCA in Geneva, Switzerland, were retrospectively included. Patients with signs of “obvious death” or with a Do-Not-Attempt-Resuscitation order were excluded. Patients were categorized as having received ALS if this was mentioned in the medical record, or, failing that, if at least one dose of adrenaline had been administered during cardiopulmonary resuscitation (CPR). Prognostic factors known at the time of EP’s decision were included in a multivariable logistic regression model. Included were 784 patients. Factors favourably influencing the decision to provide ALS were witnessed OHCA (OR = 2.14, 95% CI: 1.43–3.20) and bystander CPR (OR = 4.10, 95% CI: 2.28–7.39). Traumatic aetiology (OR = 0.04, 95% CI: 0.02–0.08), age > 80 years (OR = 0.14, 95% CI: 0.09–0.24) and a Charlson comorbidity index greater than 5 (OR = 0.12, 95% CI: 0.06–0.27) were the factors most strongly associated with the decision not to attempt ALS. Factors influencing the EP’s decision to attempt ALS in asystolic OHCA are the relatively young age of the patients, few comorbidities, presumed medical aetiology, witnessed OHCA and bystander CPR.

External validation and insights about the calibration of the return of spontaneous circulation after cardiac arrest (RACA) score

“…In particular, once that resuscitation is started from the first arrived personnel, situational and emotional aspects could have an impact on the decision to provisionally pursue resuscitative attempts even in cases with perceived futility and eventually early stop the manoeuvres. 22 , 23 , 24 This could partially explain the notable reduction in the observed versus expected ROSC rate for asystole. Moreover, in support of this hypothesis, the age-based subanalysis of calibration belts showed a better calibration of the model when assessing patients aged over 80, where asystole was less represented among the first observed rhythms (24.6% vs 30.9%), probably reflecting the higher attitude of the local EMS personnel to withdraw resuscitation in elderly people with rhythms associated to a low survival probability.…”

The 4H and 4T Pediatric Early Acute Support in the Deteriorating Child: Competent Staff Instead Experts Facing the New Threats, and New Approaches Can Reduce Mortality – Experience in Guatemala

“…High accuracy and low opportunity (HALO) are required for improving any time-sensitive intervention. The HALO applicability will require at the same time healthcare workers with enough skills and with strong commitment and knowledge for decision-making and execution of any needed action in all patients, requiring or not an intervention [11][12][13][14][15]. The early approach is based on the probability and uncertain odds of potential reversibility.…”